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Doola R, Dupuis C, Preiser JC. Nutrition support, carbohydrate feeding and insulin sensitivity in the critically ill patient: a complex relationship. Curr Opin Clin Nutr Metab Care 2024; 27:350-354. [PMID: 38712890 DOI: 10.1097/mco.0000000000001039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
PURPOSE OF REVIEW This review aims to summarize recent studies that highlight the complex relationship between nutrition, carbohydrate, insulin provision and glycaemic control in the critically ill patient population. RECENT FINDINGS Results of observational studies concur to support early hypoglycaemia and persisting hyperglycaemia as life-threatening events. In contrast, interventional studies indicate that early macronutrient restriction appears to reduce the benefits related to insulin therapy. This restriction is however associated with improved outcomes in itself. The potential role of modified enteral solutions as an adjunctive treatment to attenuate hyperglycaemia warrants further research. The selection of a therapeutic modality may also differ according to the characteristics of the setting, such as the nurse-to-patient ratio, the type and accuracy of meters, including near-continuous glucose monitoring and the availability of computer-guided protocols. SUMMARY There appears to be significant interplay between nutrition, including carbohydrate provision, blood glucose control and clinical outcomes. Individualized care is probably needed to define the optimal glucose target and nutritional intervention. This can differ according to the preexistence of chronic hyperglycaemia, the timing from the onset of critical illness and the clinical condition itself.
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Affiliation(s)
- Ra'eesa Doola
- Centre for Functioning and Health Research, Metro South Health
- Nutrition and Dietetics, Princess Alexandra Hospital, Metro South Health
- PA-Southside Clinical School, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Claire Dupuis
- Service de Réanimation, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Charles Preiser
- Service de médecine interne, HUB Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Wang L, Zhong X, Yang H, Yang J, Zhang Y, Zou X, Wang L, Zhang Z, Jin X, Kang Y, Wu Q. When can we start early enteral nutrition safely in patients with shock on vasopressors? Clin Nutr ESPEN 2024; 61:28-36. [PMID: 38777444 DOI: 10.1016/j.clnesp.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 02/17/2024] [Accepted: 03/03/2024] [Indexed: 05/25/2024]
Abstract
Shock is a common critical illness characterized by microcirculatory disorders and insufficient tissue perfusion. Patients with shock and hemodynamic instability generally require vasopressors to maintain the target mean arterial pressure. Enteral nutrition (EN) is an important therapeutic intervention in critically ill patients and has unique benefits for intestinal recovery. However, the initiation of early EN in patients with shock receiving vasopressors remains controversial. Current guidelines make conservative and vague recommendations regarding early EN support in patients with shock. Increasing studies demonstrates that early EN delivery is safe and feasible in patients with shock receiving vasopressors; however, this evidence is based on observational studies. Changes in gastrointestinal blood flow vary by vasopressor and inotrope and are complex. The risk of gastrointestinal complications, especially the life-threatening complications of non-occlusive mesenteric ischemia and non-occlusive bowel necrosis, cannot be ignored in patients with shock during early EN support. It remains a therapeutic challenge in critical care nutrition therapy to determine the initiation time of EN in patients with shock receiving vasopressors and the safe threshold region for initiating EN with vasopressors. Therefore, the current review aimed to summarize the evidence on the optimal and safe timing of early EN initiation in patients with shock receiving vasopressors to improve clinical practice.
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Affiliation(s)
- Luping Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Xi Zhong
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Hao Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Jing Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Yan Zhang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Xia Zou
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Lijie Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Zhongwei Zhang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Xiaodong Jin
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Qin Wu
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
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Stoppe C, Elke G, Silvstre SCDM, Kappus M. Highlights in the clinical nutrition literature: A critical appraisal of current research. JPEN J Parenter Enteral Nutr 2024; 48:377-388. [PMID: 38310478 DOI: 10.1002/jpen.2599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 11/30/2023] [Accepted: 12/18/2023] [Indexed: 02/05/2024]
Abstract
Within the American Society for Parenteral and Enteral Nutrition (ASPEN), the Physician Engagement Committee (PEC) was created in 2017 by the ASPEN Board of Directors with the goal of growing the physician community both nationally and internationally. The PEC meets each month throughout the year to develop educational and research initiatives. In 2022, the PEC began an initiative to systematically review and evaluate practice-changing literature annually with the overall aim to highlight these studies at the annual ASPEN conferences and to critically discuss the potential clinical implications. The objective of the held meeting session was to present identified key papers in the fields of critical care medicine, gastroenterology and hepatology, and adult internal medicine that were published in 2022, which would complement the knowledge of the pathogenesis, diagnosis, and management of nutrition topics as well as to identify areas of future research. Overall, several large-scale randomized controlled studies were identified in each of these sections, with practice-changing major results. This manuscript summarizes the information that was presented and the discussions that followed.
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Affiliation(s)
- Christian Stoppe
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
- Department of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | | | - Matthew Kappus
- Division of Gastroenterology and Hepatology, Duke University Health, Durham, North Carolina, USA
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Nguyen C, Singh G, Rubio K, Mclemore K, Kuschner W. Parenteral Nutrition in the Critically Ill Adult: A Narrative Review. J Intensive Care Med 2024:8850666241246748. [PMID: 38602149 DOI: 10.1177/08850666241246748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
Malnutrition in adult intensive care unit patients is associated with poor clinical outcomes. Providing adequate nutritional support to the critically ill adult should be an important goal for the intensivist. This narrative review aims to delineate the role of parenteral nutrition (PN) in meeting nutritional goals. We examined the data regarding the safety and efficacy of PN compared to enteral nutrition. In addition, we describe practical considerations for the use of PN in the ICU including patient nutritional risk stratification, nutrient composition selection for PN, route of PN administration, and biochemical monitoring.
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Affiliation(s)
- Christopher Nguyen
- Pulmonary, Critical Care and Sleep Medicine Section, Veterans Affairs Palo Alto Health Care System, Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Gaurav Singh
- Pulmonary, Critical Care and Sleep Medicine Section, Veterans Affairs Palo Alto Health Care System, Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Karen Rubio
- Department of Intensive Care Medicine, Kaiser Oakland Medical Center, Oakland, CA, USA
| | - Karen Mclemore
- Department of Intensive Care Medicine, Kaiser Oakland Medical Center, Oakland, CA, USA
| | - Ware Kuschner
- Pulmonary, Critical Care and Sleep Medicine Section, Veterans Affairs Palo Alto Health Care System, Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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Taylor BE, McClave SA. In the Critically Ill Obese Should We Tip the Scale With More Protein? Crit Care Med 2024; 52:671-675. [PMID: 38483225 DOI: 10.1097/ccm.0000000000006159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Affiliation(s)
- Beth E Taylor
- Department of Research, Barnes-Jewish Hospital, St. Louis, MO
| | - Stephen A McClave
- Department of Gastroenterology, University of Louisville School of Medicine, University of Louisville Health, Louisville, KY
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Patel JJ, Lopez-Delgado JC, Stoppe C, McClave SA. Enteral nutrition in septic shock: a call for a paradigm shift. Curr Opin Crit Care 2024; 30:165-171. [PMID: 38441124 DOI: 10.1097/mcc.0000000000001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to identify contemporary evidence evaluating enteral nutrition in patients with septic shock, outline risk factors for enteral feeding intolerance (EFI), describe the conundrum of initiating enteral nutrition in patients with septic shock, appraise current EFI definitions, and identify bedside monitors for guiding enteral nutrition therapy. RECENT FINDINGS The NUTRIREA-2 and NUTRIREA-3 trial results have better informed the dose of enteral nutrition in critically ill patients with circulatory shock. In both trials, patients with predominant septic shock randomized to receive early standard-dose nutrition had more gastrointestinal complications. Compared to other contemporary RCTs that included patients with circulatory shock, patients in the NUTRIREA-2 and NUTRIREA-3 trials had higher bowel ischemia rates, were sicker, and received full-dose enteral nutrition while receiving high baseline dose of vasopressor. These findings suggest severity of illness, vasopressor dose, and enteral nutrition dose impact outcomes. SUMMARY The provision of early enteral nutrition preserves gut barrier functions; however, these benefits are counterbalanced by potential complications of introducing luminal nutrients into a hypo-perfused gut, including bowel ischemia. Findings from the NUTRIREA2 and NUTRIREA-3 trials substantiate a 'less is more' enteral nutrition dose strategy during the early acute phase of critical illness. In the absence of bedside tools to guide the initiation and advancement of enteral nutrition in patients with septic shock, the benefit of introducing enteral nutrition on preserving gut barrier function must be weighed against the risk of harm by considering dose of vasopressor, dose of enteral nutrition, and severity of illness.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Christian Stoppe
- University Hospital, Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Stephen A McClave
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
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